Which of the following is most diagnostic investigation for acute pancreatitis?

Ans. b (Serum lipase). (Ref. Bailey & Love, 25th/ 1123)# A serum amylase level three to four times above normal is indicative of acute pancreatitis. A normal serum amylase level does not exclude acute pancreatitis, particularly if the patient has presented a few days later. If the serum lipase levels can be checked, it provides a more sensitive and specific test than amylase. If there is doubt, and other causes of acute abdomen have to be excluded, CECT is the best single imaging investigation.# At present, CT severity scoring (Balthazar scoring) is one of the most vital prognostic factors.SubjectiveAcute onset steady, intense epigastric abdominal pain radiating to the back with nausea and vomiting; may be relieved with leaning forward; medical history: chronic alcoholism, gallstones ObjectiveMild: Restlessness, low-grade fever, tachycardia, mild epigastric tendernessSevere: Same as mild plus marked tenderness with guarding and abdominal distension, absent bowel sounds, systemic signs of hypotension, possible shock, jaundice, and pulmonary findings, (e.g,, rales, pulmonary edema)Laboratory results: Elevated serum and/or urinary levels of pancreatic enzymes (e.g., amylase lipase, C.reactive protein, or trypsinogen activation peptide): consider liver function tests, calcium, triglycerides, albumin, complete blood count, arterial blood gases, glucoseImaging: Ultrasonography: contrast-enhanced CT or MRI (with elevated serum creatinine) and MRCP or ERCP (if high suspicion of common bile duct stones) |Differential diagnosisAcute or chronic alcohol consumption; gallstone disease; peptic ulcer disease; perforated ulcer; early appendicitis; bowel obstruction; mesenteric Ischemia; medications; hypertriglyceridemia; hypercalcemia; infection; post-traumatic injury; pregnancy; pulmonary renal or cardiovascular disorders |AssessmentRanson's CrilteriaAPACHE IICT Severity Index Mild pancreatitis <3Severe pancreatitis >3<8>8<7>7 ||PlanManagement of mild pancreatitis- Aggressive rehydration (i.e., dextrose in normal saline at 1 L per hour until adequate urine output)- Pain relief (morphine)- Enteral nutritional support once pain improves and laboratory results normalize- Monitor hemodynamic and laboratory/ serum parameters Management of severe pancreatitis- Consider intensive care unit admission- Eliminate oral intake for first 48 hours- Aggressive volume replacement- Nutritional support (enteral preferred)- Consider emergency ERCP with suspected gallstones and obstructive jaundice- Pain relief (morphine)- Identify if pancreatic or peripancreatic necrosis is present- Consider antibiotics if possible infection- Consider consultation with gastroenterology, surgery, and/or interventional radiology subspecialists